Introduction

Open and arthroscopic hip debridement may be used for treatment of femoral acetabular impingement (FAI). There is a paucity of evidence regarding the efficacy of one over the other.

Introduction

Open hip debridement surgery has been used for treatment of femoral acetabular impingement pain for over ten years in our unit. While literature has reported promising short-term outcomes, longer term outcomes are more sparsely reported.

Introduction

Open hip debridement surgery has been used for treatment of femoral acetabular impingement pain for over ten years in our unit. While literature has reported promising short term outcomes, longer term outcomes are more sparsely reported. We aim to assess survivorship and functional outcome at ten years, in patients who have undergone open hip debridement.

This study reviewed all patients who received an EXOGEN Express bone stimulating device (BSD) to treat delayed union / non-union following operative treatment for a long bone fracture & evaluate if our results are comparable with the NICE guideline expectations.

A retrospective review of records between December 2004 & January 2013 revealed 113 patients treated with a BSD. A total of 59 patients were eligible for analysis, (operative treatment for a long bone fracture with adjuvant EXOGEN BSD for non-union or delayed union). Twenty-one were open fractures.

The BSD was applied at a mean of 264 days post-operatively. Thirty-five patients went on to have a 2nd operation before union was achieved. Forty-two patients went on to union following application of the BSD. Mean time to union was 293 days. Seventeen patients failed to unite by the end of the study. There were no adverse reactions to the EXOGEN BSD in this cohort.

This study has shown that the use of an EXOGEN BSD is a safe, non-invasive method to successfully treat long bone non-unions following initial operative surgery, with potential cost savings (a potential saving of £48,888 to the hospital according to NICE estimations) compared to the standard re-operative management.

Routine postoperative radiographs following hip hemiarthroplasty are commonly undertaken despite it being suggested that they can cause delays to discharge, discomfort to patients and unnecessary radiation. Our study considered the necessity of these post-operative radiographs.

A retrospective search was conducted of all hemiarthroplasty procedures on the Royal Cornwall Hospital database. These were reviewed for cases where re-operation was conducted within 6 weeks. Notes and post-operative check radiographs of those who underwent re-operation were reviewed to determine how essential radiographs were in diagnosing complications requiring re-operations.

A total of 1557 hemiarthroplasty operations were identified. There were 37 incidences of re-operation within 6 weeks. 29 cases had normal check radiographs. 8 dislocations were picked up on post-operative radiographs. In all but one of these cases, clinical suspicion of complication had been raised prior to the radiograph. In the remaining case documentation was poor and no firm conclusion as to clinical suspicion could be drawn.

Our review of over 1500 hemiarthroplasty cases, demonstrated one incident where the check radiograph solely diagnosed an abnormality needing intervention that might not have been apparent clinically. We thus suggest that check radiographs following hip hemiarthroplasty should not be routinely ordered for all patients.

Aim

To review the patients that have undergone correction of a symptomatic femoral malunion using osteotomy combined with decortication.

We reviewed patients that have undergone correction of a symptomatic femoral malunion using osteotomy combined with decortication by retrospective reviewing all patients who have undergone the procedure, looking at the pre-operative deformity, correction achieved, time to union and complications.

Seven patients underwent correction under the senior author from 2003 to today. Average age was 46 years (range 32–60 years). All had femoral shortening, average 2.7cm (range 2–4 cm). Each also had at least one other plane of deformity with rotation being the next most commonly encountered in 5 out of the 7 (average 33 degrees). 2 had tri-planar deformity with the 5 having bi-planar deformity. Average time to union was 18.4 months (range 7 to 39 months) with an average of 1.6 operations (range 1 to 3 operations) to union. Two patients are awaiting union, 1 has required repeat plating and one is a primary fixation and correction awaiting union.

Correction of multiplanar deformity of the femur is challenging. Osteotomy with decortication provides a technique to achieve correction of significant femoral deformity union achieving full multi-planar deformity correction in a single operation. This paper provides guidance and a technical description of the operative technique.

The purpose of this study was to investigate whether patients who had had excision of the Ligamentum Teres as part of a surgical hip dislocation for femoro-acetabular impingement exhibited symptoms of acute Ligamentum Teres rupture post-operatively. Recent reports in the literature suggest that injury to the Ligamentum Teres can cause instability, severe pain and inability to walk.

We present the results of a postal questionnaire to 217 patients who had undergone open surgical hip dislocation for femoro-acetabular impingement where the LT was excised. This included seven patients who had undergone bilateral surgery. The questionnaire was designed to enquire about specific symptoms attributed to LT injuries in the literature; gross instability, incomplete reduction, inability to bear weight and mechanical symptoms.

161 patients responded (75%), with a total of 168 (75%) questionnaires regarding 224 hips completed. There were 104 females and 64 males. Median age was 34 and median follow-up was 52 months. All patients were found to have cam deformities, 72% (n=121) had associated labral tears. All patients were able to fully weight bear after surgery. 77% experienced no groin pain and 61% experienced no pain on exercise. 35% of patients experienced popping and locking in their operated hip and 24% had subjective feeling of their hip giving way. Oxford Hip scores and Nonarthritic Hip scores improved by 12 and 28 points respectively (n=47).

Our results show that the symptoms of pain and instability described with LT pathology can be present but are by no means universal. This leads us to conclude that their symptoms may be attributed to labral pathology which is frequently noted to coexist.

The treatment of nonunion is challenging providing the surgeon with a variety of different surgical options in order to encourage and achieve bone consolidation. Despite excellent results presented in 2008 of 99% union rates, Judet Osteo-Periosteal Decortication does not seem to be popular at present with bone grafting and distraction osteo-modelling being the favoured option.

Retrospective analysis was performed from December 2002 to December 2008 of 46 cases of osteoperiosteal decortication(Judet technique) for failure of fracture union.

Union was successfully achieved in 39 of the 45 patients(85%) after a mean delay of 10.7 months(range 3-39 months). Thirty patients(65%) achieved union following the decortication procedure without subsequent operations. The mean number of procedures following decortication was 0.6(range 0-4) mostly being performed for metalwork failure. Metal work failure occurred in 13 cases(28%) with the majority occurring in decortications of the femur(n=11,85%). The femur was the location of all persistent non unions in the series. The nonunion scoring system(0-100,Calori et al 2008) means were noticeably worse for the persistent nonunion group(41.67, range 34-46) compared to the union group(29, range 4-52).

Osteoperiosteal decortication remains a highly effective surgical technique in the management of failed fracture union.

Introduction

Femoroacetabular impingement (FAI) is a relatively recent recognised condition and a potential cause of anterior hip pain in the young military adult population. Both Cam and Pincer type FAI may lead to inflammation, labral tears, and or damage to the smooth articular cartilage of the acetabulum leading potentially to early osteoarthritis of the hip. Open Surgical hip dislocation using the Ganz Trochanteric Flip approach is an accepted technique allowing osteoplasty of the femoral neck and acetabular rim combined with labral repair if required. We present our results of this technique used in military personnel.

Introduction

Femoroacetabular impingement (FAI) causes anterior hip pain, labral tears and damage to the articular cartilage leading to early osteoarthritis of the hip. Surgical hip dislocation and osteoplasty of the femoral neck and acetabular rim is a technique pioneered by the Bernese group for the treatment of FAI. We present and discuss our results of this technique.

Periprosthetic Hip Fractures (PHFs) and Complex Revision Hip Arthroplasty(CRHA) consistently present challenging management decisions. Extramedullary devices alone or in combination with strut graft or long stem prosthesis revisions (cemented and uncemented) have all been described as treatment options. A long distal locked femoral stem provides an alternative allowing immediate stability for weight bearing without impaction bone grafting or external plate fixation and strut grafting. It has a lower risk of subsidence.

24 patients underwent a Cannulok Stem procedure from 2003–2008. Each was reviewed regularly following surgery with clinical examination and Hip scores (Oxford and SF12). The indications for device use, Vancouver classification if a periprostheic fracture, radiological evidence of union and complications were all recorded from medical and radiological records. The results were then compared to similar studies.

The indications for Cannulok use were periprosthetic fracture (50%), infection with bone loss (12.5%), revision for aseptic loosening (33.3%) and subtrochanteric fracture post arthrodesis and metalwork removal (4.2%).

A 75% union rate was seen in periprosthetic fractures. There were 2 deaths, 2 deep infections and 1 superficial infection. The 40 mm offset stems resulted in 6 (25%) dislocations compared to 0% dislocations with the 45 mm offset stem. In addition there was 1 femoral stem revision for subsidence (no distal locking screws used) and 1 acetabular revision. There was an average follow up of 20 months.

This study suggests that the Cannulok Plus femoral reinforcement stem is a potential alternative treatment option in PHFs and CRHA with acceptable complication rates.

Heterotopic ossification is a recognised complication of surgery on the hip joint that can adversely affect the outcome. The aim of this study was to determine the incidence of heterotopic ossification following surgical hip dislocation and debridement for femoro-acetabular impingement using Ganz trochanteric flip osteotomy approach. We also compared the incidence of heterotopic ossification between two subgroups of patients; in the first group, a shaver burr was used to reshape the femoral head and in the second group, an osteotome was used.

Methods: We reviewed postoperative radiographs of all patients who underwent surgical hip dislocation and debridement during the period between March 2003 and July 2007. We excluded patients with radiographic follow-up of less than one year. Brooker classification was used to grade heterotopic ossifications.

Results: Ninety eight patients (mean age 35 years, range 12–65 years) were included with a mean radiological follow-up of 23 months (range 12–61 months). The overall incidence of heterotopic ossification was 31%. None of the patients developed Brooker grade III or IV heterotopic ossifications. The incidence of heterotopic ossifications in the shaver burr group (n=57) and in the osteotome group (n=41) was 30% and 32%, respectively.

Conclusions: Heterotopic ossification of minor grade is a common complication of surgical hip dislocation using trochanteric flip osteotomy approach. The use of a shaver burr did not result in higher rates of heterotopic ossifications despite the formation of large amounts bone debris.

The aim of Femoro-Acetabular Impingement (FAI) surgery is to improve femoral head-neck clearance by resection of the osseous bump deformity. The purpose of this study was to investigate whether osseous bumps will re-grow and to compare two instruments used for resection osteoplasty; a shaver burr and an osteotome.

We reviewed records of patients who underwent surgical hip dislocation and debridement via Ganz flip osteotomy between March 2003 and July 2007. We excluded patients with less than one-year radiographic follow-up.

Ninety-five patients (95) underwent 98 surgical hip dislocations and were included (mean radiological follow-up 23 months, range 12–61 months). Bump re-growth occurred in 16 cases (16%). Pre and postoperative Non-Arthritic Hip Scores (NAHS) were available for 12 of the 16 patients. The mean pre- and postoperative NAHS were 62 (range 26–95) and 83 (range 41–104) respectively (p= 0.02). In the shaver burr group (n=57), there were 6 cases of bump re-growth (12%) compared to 10 cases in the osteotome group (n=41) (32%).

In this study, recurrence of osseous bumps did not affect the outcome. Using shaver burrs resulted in lower rates of bump re-growth than using osteotomes. This could be related to heat osteonecrosis at the femoral head-neck junction.

We report a 10% failure rate for aseptic loosening and overall revision rate of 15% at 5 years mean follow up in 190 patients using the Cormet 2000 Dual coat ace-tabular component.

Between April 2001 and March 2004, this cup was used in our region by 4 surgeons. It was peripherally expanded and comprised a cobalt chrome shell, plasma sprayed with a further layer of cobalt chrome which was then coated with hydroxyapatite. This backing has since been abandoned in favour of a titanium plasma coat beneath the hydroxyapatite because of a higher than expected incidence of early loosening.

There were 190 cups implanted in 174 patients, 142 with resurfacing heads. The average age was 54 and 99 were male.

Revision for aseptic loosening was required in 20 cups (10%) at a mean interval of 23 months including five within 2 months, Of the early revisions three developed a deep infection. Undiagnosed groin pain in four further patients appeared at revision to arise from an inflamed bursa secondary to impingement of psoas tendon on the rim of the cup. There was one primary infection, one infection following revision of a trochanteric osteotomy and two neck fractures. Persistent unexplained groin pain was seen in three patients who have declined further surgery

Failure of this backing to integrate with bone led to an unacceptably high early loosening rate. Positioning of the larger resurfacing cups is critical to avoid painful irritation of psoas. Early revision carries a high risk of infection.

Between January 2003 and December 2004, 14 patients underwent bilateral resurfacing arthroplasty via a Ganz trochanteric osteotomy. This bilateral group was mobilised fully weight-bearing with crutches. During the same period 139 Ganz trochanteric osteotomies were performed for unilateral hip resurfacing. These patients were mobilised with crutches, weight-bearing up to 10 kg on the operated leg.

Nine osteotomies (32%) in the bilateral group subsequently developed a symptomatic non union requiring revision of fixation. This compares with 10 patients (7%) in the unilateral group. Applying the Fisher’s exact test, the difference reached significance (p=0.0004). In 2 patients a second revision was required to achieve union. In 1 patient, revision of trochanteric fixation precipitated a deep infection.

Protected weight-bearing following a Ganz trochanteric osteotomy is important to the success of the procedure. Simultaneous bilateral hip arthroplasty through a Ganz approach should be avoided. If it is undertaken, we recommend that patients should be non weight-bearing for 6 weeks following surgery. Non union following a Ganz trochanteric osteotomy for arthroplasty carries a significant morbidity.

Since 2003 we have adopted an aggressive approach to the management of slipped upper femoral epiphysis (SUFE) deformity, an important cause of femoro-acetabular impingement and associated with the development of early adult hip arthritis.

Sixteen patients aged 16.7 years (range 11–20), 13 male, have undergone surgery to manage their SUFE deformity. Nine underwent primary surgery using a Ganz approach (7) or in-situ pinning with femoral neck resection via a Smith-Peterson approach (2). Seven had previously undergone in-situ pinning 26 months earlier (range 4–44 months) of whom two had acetabular chondral flap tears with eburnated bone and six had significant labral degenerative changes associated with calcification or tears. Only one of the nine patients who underwent primary aggressive management of their SUFE, had a labral tear. Four patients underwent mobilisation of the femoral head on its vascular pedicle, followed by anatomical realignment.

At an average follow-up of 22.3 months (range 1–41 months) 15 remained well with excellent function. Leg lengths remained equal in 12, with average shortening of 2 cm in the remaining four. Segmental AVN occurred in the first patient after damage to the vascular pedicle during drilling of the neck; the technique has been modified to prevent this.

Despite having performed over 400 surgical hip dislocations, the authors continue to find the management of this condition challenging; nevertheless, having seen the consequences of femoro-acetabular impingement in these young patients, we believe that aggressive management to correct anatomical alignment is essential for the future well being of the hip.

Introduction: Femoroacetabular impingement (FAI) is an important cause of hip pain in young adults and a precursor to osteoarthritis. Morphological abnormality of either the acetabulum, proximal femur, or both, may result in FAI. The majority of patients however, have a cam deformity of the proximal femur. From a research perspective, FAI is an example of how subtle morphological abnormality results in a predictable pattern of cartilage damage, and thereby offers great potential as a model to study early degenerative disease and for clinical trials of joint preserving treatments. Accurate classification of the morphology of the hip is essential for this further study.

The aim of this study was to define normal, borderline, and abnormal parameters for the morphology of the proximal femur, in the context of the cam deformity, by studying asymptomatic individuals with normal clinical examination and no osteoarthritis from the general population.

Methods: 157 individuals (79 male, 78 female, mean age 46 years) with no previous history of hip problems were recruited. The participants were the spouses/partners of patients involved in a cohort study of osteoarthritis and FAI. All participants underwent clinical (interview, examination, and hip scores) and radiological assessment (standardised AP Pelvic and cross-table lateral radiographs of each hip). Radiographs were scored for the presence of osteoarthritis, and the morphology of the proximal femur was analysed. The alpha angle, anterior offset ratio, presence of a cam ‘bump’, synovial herniation pit were recorded in each hip.

Results: 21 subjects were excluded because they either had positive clinical features or radiological evidence of osteoarthritis (equivalent to a Kellgren and Lawrence grade of 2). From the remaining 136 subjects, with essentially ‘normal hips from the general population’, mean values for the alpha angle and anterior offset ratio were generated. Borderline and Abnormal values are suggested. Gender differences were noted with higher mean alpha angles and lower offset ratios occurring in men.

Discussion: Although it has limitations, standardised plain radiography remains the cheapest and most convenient way to screen an individual for the presence of a cam deformity. Despite the recent interest in FAI, our knowledge of what is normal in the general population, as assessed using appropriate radiographic techniques, is modest. The ranges provided by this study will facilitate the accurate classification of subjects with FAI, thereby providing guidance for surgeons treating such patients, and also enable the generation of refined cohorts for the study of the natural history of subtle morphological abnormalities of the hip, and for enrolment in clinical trials.

Introduction: Femoroacetabular impingement (FAI) is an important cause of hip pain in young adults and a precursor to osteoarthritis. Genetic factors are important in the aetiology of osteoarthritis of the hip. From a research perspective, FAI is an example of how subtle morphological abnormality results in a predictable pattern of cartilage damage, and thereby offers great potential as a model to study early degenerative disease.

Although many causes of FAI are described, the vast majority of patients give no history of previous hip disease. The purpose of this study was to investigate the extent to which FAI has an underlying genetic basis, by studying the siblings of patients undergoing surgery for FAI and comparing them with controls.

Methods: 66 patients (probands, 29 male, 37 female, mean age 39.1 years) treated surgically for FAI provided siblings for the study. These patients were classified as having cam, pincer or mixed FAI. 101 siblings (55 male, 56 female, mean age 38.2 years) were recruited. The control group consisted of the 77 partners of those siblings (40 male, 37 female, mean age 41.9 years). All subjects underwent clinical (interview, examination, and hip scores) and radiological assessment (standardised AP Pelvic and cross-table lateral radiographs of each hip). Radiographs were scored for the presence of osteoarthritis, and cam- and pincer-type abnormalities.

Results: Participants were classified as a) Normal morphology with no clinical features, b) Abnormal morphology but no clinical features c) Abnormal morphology with clinical signs but no symptoms, and d) Abnormal morphology with symptoms and signs. The sibling relative risks were significant for groups b, c, and d, supporting the hypothesis of an underlying genetic predisposition to FAI. Siblings usually demonstrated the same type of abnormal morphology as the proband. Gender specificity was apparent however, with pincer abnormalities which were usually apparent in female probands being common in sisters but less common in brothers. The brothers of probands with cam deformities almost universally demonstrated the same deformity, although only 50% of sisters did so.

Discussion: Genetic influences are important in the aetiology of FAI. Whether the morphological abnormality is determined at conception or by an inherited predisposition to an acquired event during maturity warrants further study. We have identified a spectrum of disease with a proportion of siblings with abnormal morphology currently asymptomatic. These cohorts present an opportunity to prospectively study the natural history of the condition, improve our understanding of the mechanisms and pathology in early degenerative disease, and potentially to be recruited into clinical trials of surgical and adjuvant treatments.

Introduction: Femoroacetabular impingement (FAI) causes pain in young adults and osteoarthritis. Genetic factors are important in the aetiology of osteoarthritis. We aimed to investigate the extent to which FAI has an underlying genetic basis, by studying the siblings of patients undergoing surgery for FAI and comparing them with controls.

Methods: 66 patients (probands, 29 male, 37 female, mean age 39.1 years) treated surgically for FAI provided siblings for the study. Probands were classified as having cam, pincer or mixed FAI. 101 siblings (55 male, 56 female, mean age 38.2 years) were recruited. The control group consisted of their 77 partners and was age and gender-matched. All subjects were assessed clinically and radiologically (standardised AP Pelvic and cross-table lateral radiographs of each hip). Radiographs were scored for the presence of osteoarthritis, and morphological abnormalities.

Participants were classified as:

Normal morphology, no clinical features

Results: The sibling relative risks were significant for groups b, c, and d (ranging between 2–5, p< 0.01). Pro-bands and siblings shared the same pattern of abnormal morphology. Gender specificity was apparent: pincer abnormalities common in sisters but not in brothers. The brothers of probands with cam deformities almost universally demonstrated the same deformity, but only 50% of sisters did.

Discussion: Genetic influences are important in the aetiology of FAI. Whether the morphological abnormality is determined at conception or by an inherited predisposition to an acquired event during development warrants further study. Symptoms are variable, indicating a spectrum of disease progression. These cohorts present an opportunity to prospectively study the natural history of the condition, improve understanding of the mechanisms and pathology, and potentially to be recruited into clinical trials.